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Schatzkis Ring. an Unusual Clinical and Radiological Presentation

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Schatzkis Ring. an Unusual Clinical and Radiological Presentation Case Reports Sameer Pusalkar, MD, Tarek E. Abdellatif, MD. ABSTRACT Schatzki’s ring is a lower esophageal mucosal ring associated with a small sliding hiatus hernia. Most investigators described it as either an asymptomatic or symptomatic entity with chronic recurrent presentation of dysphagia. Barium swallow study in patients with Schatzki’s ring was described as a thin smooth circumferential constriction at the GE junction. This case report describes an unusual clinical and radiological presentation in a patient with Schatzki’s ring. Our adult male patient experienced sudden dysphagia, followed by spontaneous relief after an interval of 12 hours without specific treatment. Radiological findings were highly suggestive of lower esophageal malignancy. However, this possibility could be excluded by upper endoscopy and histopathological examination of biopsies taken from the lesion. The condition was diagnosed as Schatzki’s ring with unusual clinical and radiological presentation. Saudi Med J 2005; Vol. 26 (3): 467-469 chatzki’s ring is a lower esophageal mucosal Case Report. A 58-year-old, American male S ring associated with a small sliding hiatus presented with sudden and complete dysphagia, hernia.1,2 Most investigators described it as either which was followed by spontaneous relief after an asymptomatic or symptomatic entity with chronic interval of 12 hours. This was a single episodic and recurrent presentation of dysphagia.3 The presentation by the patient. Dysphagia did not incidence of symptomatic Schatzki’s ring is follow a particular type of solid food intake such as reported to be approximately 0.5% in patients meat. Also, patient did not have any associated undergoing routine upper gastrointestinal (GI) abdominal, thoracic or constitutional symptoms. barium examination.4 In barium swallow study, Clinical examination of the patient was Schatzki’s ring is described as a thin smooth unremarkable. Barium swallow was carried out circumferential constriction at the gastroesophageal shortly after presentation and this showed complete (GE) junction. We are reporting a case of Schatzki’s obstruction at the lower end of esophagus with an ring presented with unusual clinical and radiological irregular filling defect and shouldering sign manifestations that closely mimicked lower (Figures 1 & 2). These findings were highly esophageal carcinoma. This case report pays suggestive of lower esophageal malignancy. The attention to the importance of full investigations and patient was admitted, received no specific treatment close follow up of patients with Schatzki’s ring to but was put under observation and was given exclude the possibility of esophageal malignancy. intravenous fluids and nothing by mouth. Twelve From the Department of Radiology (Pusalkar) and Department of General Surgery (Abdellatif), Ghassan Najeeb Pharaon Hospital, Khamis Mushayt, Kingdom of Saudi Arabia. Received 30th August 2004. Accepted for publication in final form 4th December 2004. Address correspondence and reprint request to: Dr. Tarek E. Abdellatif, Consultant Surgeon and Laparoscopist, GNP-Hospital, PO 761, Khamis Mushayt, Kingdom of Saudi Arabia. Tel. +966 (7) 2200002 Ext. 604. E-mail: [email protected] 467 Schatzki’s ring … Pusalkar & Abdellatif hours following admission, the patient experienced spontaneous and complete relief of dysphagia. Follow-up radiological exposure was taken after relief of dysphagia revealed free passage of barium through the esophagogastric junction into the stomach. The next day of hospitalization, an esophagogastroscopy was performed which did not show any evidence of tumor mass, instead, it showed a constricting ring at the lower end of oesophagus accompanied by a sliding hiatus hernia, and a tiny ulcer over the crater of the ring (Figure 3); signs suggestive of gastro-esophageal reflux disease (GORD). Biopsies taken from the lesion site for histopathological examination revealed no signs of malignancy. The case was diagnosed as Schatzki’s ring of lower end of esophagus. The patient was Figure 1 - Barium swallow showing complete arrest of the dye at the discharged on the second day of admission free and esophagogastric junction and irregular filling defect. was given omeprazole for treatment of GORD and lower esophageal ulcer. Follow up of the patient for about one year did not report any recurrence of the symptoms or abnormal radiological or endoscopic findings. Discussion. Schatzki’s ring was first described in literature by Schatzki and Gary in 1953.5 The exact pathogenesis of these rings is unknown. Most investigators believe that Schatzki’s ring is an annular ring-like stricture caused by scarring as a result of reflux esophagitis.4,6 The luminal diameter of mucosal ring is the primary factor that determines the presence or absence of dysphagia.7 In 1963, Schatzki reported that if the luminal diameter of ring is less than 13 mm, patients regularly experience intermittent dysphagia to solid food.8 Some patients may present with acute food impaction causing an obstruction. It occurs that a large piece of meat becomes stuck at the level of Figure 2 - Barium swallow showing shouldering sign at the ring, hence the term steakhouse syndrome. On the esophagogastric junction which mimics carcinoma of the lower esophagus. other hand, the clinical course of Schatzki’s ring shows that if the patient passes or regurgitates the food bolus the symptoms resolve. Perforation of esophagus is an extremely rare, but important complication of Schatzki’s ring and occurs after meat impaction with only one such case reported until date.9 There is no age bar for the development of Schatzki’s ring and it can also present in children.10 In our case, patient did not give history of specific type of solid food intake shortly before development of dysphagia. Also, he had a complete relief of dysphagia without regurgitation of food. Thus, the patient did not receive any of specific treatment for Schatzki’s ring but only for the associated GE reflux and the tiny ulcer at lower end of the esophagus. Barium swallow study in patients with Schatzki’s ring at the time of dysphagia is Figure 3 - Esophagogastroscopy showing constricting ring at the expecting to show a thin smooth circumferential esophagogastric ring with a tiny ulcer over its crater. constriction at the GE junction.5 In our case we 468 Saudi Med J 2005; Vol. 26 (3) www.smj.org.sa Schatzki’s ring … Pusalkar & Abdellatif describe a rare radiological presentation of episodic References Schatzki’s ring in which barium swallow findings 1. Chapman AH. The salivary glands, pharynx and esophagus. closely mimicked lower esophageal malignancy In: Sutton D, editor. Textbook of radiology and imaging. regarding the presence of irregular filling defect and New York, Edinburgh, London, Madrid: Churchill shouldering sign. However, endoscopy and Livingston; 1998. p. 803-804. histopathological examination of tissues taken from 2. Hendrix TR. Schatzki ring, epithelial junction and hiatus hernia: An unresolved controversy. Gastroenterology 1980; the site of lesion excluded malignancy. There is no 79: 584-585. reported evidence of association of Schatzki’s ring 3. Zaveri JP, Nathani RR, Shah RL. Schatzki’s ring: An and esophageal malignancy.7 Generally, treatment obscure cause of dysphagia (case report). J Post Grad Med 1987; 33: 99-101. of Schatzki’s ring is offered only in the 4. Johnson AC, Lester PD, Johnson S, Sudarsanam D, Dunn symptomatic group of patients and the choices of D. Oesophagogastric ring: why and when we see it, and treatment include dilatation and rupture of ring or what it implies: a radiologic-pathologic correlation. South Med J 1992; 85: 946-952. excision of ring with repair of hiatus hernia. The 5. Schatzki R, Gary JE. Dysphagia due to diaphragm-like recurrence rate of symptoms is considerably high localized narrowing in the lower esophagus (lower after dilatation. On the other hand, surgical option is esophageal ring). Am J Roentgenol 1953; 70: 911-922. 6. Bugden WF, Delmonico JE Jr. Lower esophageal Web. J reserved only for patients with reflux as Thorac Surg 1956; 31: 1-18. predominant complaint rather than dysphagia with 7. Marshall JB, Kretschmar JM, Diaz-Arias AA. the realization that there will be a sizable failure Gastroesophageal reflux as a pathogenic factor in the rate. Radiological and endoscopic follow up of our development of symptomatic lower esophageal rings. Arch Inter Med 1990; 150: 1669-1672. patient for one year did not show recurrence of 8. Schatzki R. The lower esophageal ring: Long-term follow symptoms and even the ulcer in the lower up of symptomatic and asymptomatic rings. Am J esophagus healed completely. Roentgenol Radium Ther Nucl Med 1963; 90: 805-810. 9. Buckley K, Buonomo C, Husain K, Nurko S. Schatzki ring in children and young adults: clinical and radiological Acknowledgment. The authors would like to thank Mrs. findings. Pediatr Radiol 1998; 28: 884-886. Andrea Fernandez and Mrs. Nelia Enriquez from the 10. Miller S. Hines C Jr, Ochsner JL. Spontaneous perforation department of imaging for their assistance in preparing this of the esophagus associated with a lower esophageal ring. manuscript. Am J Gastroenterol 1988; 83: 1405-1408. www.smj.org.sa Saudi Med J 2005; Vol. 26 (3) 469.
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